Frederic Fransen postulates an alternative vision for health care provision among Mennonites in traditional Amish-style "mutual aid" fashion—a Two Kingdoms ideal Fransen founds on the fourth article of the Schleitheim Confession. At the same time, Fransen is a strong ideological proponent of a form of health care decision-making that is consistent with free market principles and a core libertarian philosophy of free choice unencumbered by "the gun" of government coercion. That these two thought streams are wedded in a single proposal is remarkable.

Fransen is to be commended for contributing unambiguously original thoughts to the ongoing conversation within Mennonite Church USA around questions of health care access. The wide range of issues and interrelated arguments that he addresses in his article illustrates well the complexity of health care access questions.

While the ideal of mutual aid among Mennonites as a solution to the health care access problems in 21st century America is appealing, this respondent does not believe that Fransen has proposed a viable alternative to current health insurance approaches—whether private (including Mennonite Mutual Aid health insurance) or public in nature. Existing factors driving up the cost of health care are not fundamentally resolved in Fransen's proposal, while at the same time additional difficulties would likely be created by such a plan.

The bulk of my response will probe what I perceive to be the economic and decision-making logic implicit in Fransen's proposal. I will leave it to others to debate the validity of using a Two Kingdoms argument to justify opposition to any form of publicly-run universal health insurance plans.

Fransen's apparent purpose in writing this essay is to take issue with "Mennonite position papers on health care access (that) advocate extension of health insurance coverage to all Americans." His counter proposal would essentially establish a health care plan in which Mennonites could voluntarily join and share in each others' medical expense burdens. He advocates this as a preferred alternative to "the idea of third-party payer financing of health care through national or other compulsory insurance proposals."

For Fransen, a primary attraction of such a Mennonite group is that participation would truly be a matter of choice for each individual—in the same way that the decision to seek baptism and membership in an Anabaptist community is to be completely voluntary. This is attractive to Fransen because of his presumption that a group of Mennonites, united in a common theology, would be much more likely than other secular health care groups to share similar values about difficult medically-related decisions (e.g., what specific procedures to cover at what price under what circumstances and for whom.)

He presumes the outcome of this in-house Mennonite process would be preferred to the outcome of decisions from insurance plan administrators or government bureaucrats. The biggest problem facing contemporary insurance programs, Fransen suggests, is that their administrators "cannot tabulate all the information about each and every individual's needs…much less take either their needs or their values into account when setting policy." By contrast, Fransen envisions a Mennonite health group eliminating such third-party payers and decision makers from the health care process, leaving "doctors, hospitals, and their patients" in charge of health care decisions. For Fransen, this is not just a practical decision-making improvement, it also has built in theological advantages: "One of the reasons Schleitheim rejects the ability of people outside God's Grace to do good is because without Grace, people cannot know enough about what any good is to pursue it. On the account of Schleitheim, such knowledge is only available to those within the Church."

It appears that Fransen sees health care decisions as more of a series of potentially difficult moral choices (better for the church to make) than as an interconnected set of complex technical decisions (better for scientific and cost experts to make.) Clearly, there are both types of decisions at play in the current health care access dilemma. The question comes down to where best to lodge the decisions, given the strengths and limitations of each group—and indeed, whether there might be some "third way" hybrid that finds ways to allow both domains of decision makers to remain involved.

Since Fransen has focused almost exclusively on challenges the current insurance model faces, it might be helpful to elucidate challenges that Fransen's mutual aid model would likely encounter. A significant danger in any voluntary health plan is what economists describe as a natural tendency towards "adverse selection." Simply put, people who have reason to believe they have a higher probability of needing to use medical services are much more likely to want to participate in a group that "shares the burden" than do those who believe their odds of needing medical care are low. Most "sick" people will opt in to a self-selected group, while any number of "healthy" people will choose to forego insurance for their limited medical needs. But as a consequence, the average medical costs of those who join such groups end up being much higher than those of the general population.

Fransen's proposal acknowledges the need for a 75 percent participation rate of Mennonites to keep this sort of problem manageable. Assuming that the dollar cost of participation in a plan with "good" coverage would be high (because there's no getting around the fact that today's high tech medical procedures and drugs have become very expensive), it seems very much like an open question as to whether a high voluntary participation rate is realistic. An alternative is possible—offering a more affordable plan that also covers far fewer medical contingencies—but would create a whole new set of dilemmas and stresses for participants.

Herein lies a fundamental advantage of using legislative power to force 100 percent participation in a health insurance program (whether publicly or privately administered.) It keeps the average cost of health care as low as possible for everyone—including the chronically ill. Fransen refers to such a mandatory program as "using the weapons of government to take money from some people to pay for the health care of others…with resources collected at the point of a (tax collector's) gun…" Yet if one recognizes that the point of using such coercion is to eliminate "adverse selection" and create the lowest possible average health care costs for the whole population, perhaps enforced participation can be seen in a different and more positive light. (It is also worth considering the type and extent of verbal or moral "coercion" that might need to come from within the church to generate adequate rates of participation in a voluntary proposal—and to ponder whether it's wise for that sort of potential stress to be associated with one's place of worship.)

A second fundamental problem that Fransen's proposal cannot address is what economists call "imperfect competition" in health care markets. Simply put, for quite a number of structural reasons, the sellers of health care (doctors, hospitals, drug companies) have considerably more power over prices than do the consumers of health care (individual patients). Preferred provider organizations (such as ones that Mennonite Mutual Aid offers access to) that negotiate prices on behalf of their member patients with the sellers of health care have become the most effective ways to keep in check the higher prices and excess profits that would otherwise result from this structural imbalance of power between seller and buyer. Significant discounts in hospital and physician fees and drug prices have resulted.

Would even 100,000 Mennonites widely scattered across the U.S. be able to negotiate on their own with the many sellers of health care wherever Mennonites reside—or would they end up paying full list prices whenever they see the doctor? Who would do the negotiating and how much time, effort, and expertise would that take?

Other difficulties would be encountered. Fransen envisions a reality that would "allow ethical communities…distinct rules for themselves, rules which apply only to members." This is an attractive thought. But what would those rules (a synonym for rationing decisions) need to look like in order for the cost of medical care to add up to what is affordable by the group? As is the case under current insurance plans, very tough choices about granting access to expensive treatments will still be necessary—only now, those who must do the rationing will potentially be personal friends and prayer partners of those who are ill. This scenario might well have as many down sides as up sides.

Finally, several questions of extension are logically triggered by this proposal. Fransen makes no reference to Medicare—a universal publicly-run health insurance program for senior citizens that generally receives broad public support. Should Mennonites also oppose Medicare on principle? If "anonymous" insurance should be resisted by Mennonites in the area of health care, how about other forms of insurance—for life, automobiles, property, liability, etc? If Schleitheim would compel Mennonites to separate from government and "civic affairs" in matters related to health, why not also for other government functions?

Fransen is to be commended for his sincere and forthright attempt to find a way to reconcile political differences within the Church regarding universal health care access. But to this reviewer it appears that the proposed alternative comes at the expense of a whole new set of both economic and practical challenges.